Lots of text, but a few things I'd like to comment on, and a few pinocchio's I'd like to issue. As a caveat, I am a surgical subspecialty resident, so this is all written from my point of view.
a) Nurse practitioners function equally well as 3rd year residents.
10 pinocchios. In regards to these matters, you can't speak in absolutes, because there will always be that one nurse practitioner who is exceptionally good and that one MD who is exceptionally bad, but on the whole this is a false statement, especially as it has been mentioned that you have DNP's coming directly out of school with no more real experience than a medical student. From my experience, even seasoned nurse practitioners function on the level of an late PGY-1, early PGY-2, and from my experience working on the wards, the attendings have a much greater expectation of the residents to perform than for the nurse practitioners. When I was on the wards, the nurse practitioners worked shifts during the day covering about 1/3 the number of patients that I did, and the interns covered all nights and weekends. Logic would say dictate that when you cover 1/3 of the patients, you should have 3x more time to spend with each patient you care for. This is what irks me when patients complain about how little time they actually spend with physicians. When their shift was over, they were going home, regardless of the work they had left to do; that work was passed onto the interns. Yet, they make twice as much as I do as a resident. Go figure. Where I train, the 3rd year residents across all the surgical specialties are far more competent in patient care than the nurse practitioners; those final 2 years of training are really spent ensuring that surgical skills are adequate to operate alone.
In the course of one day my responsibilities include rounding at 5:30am, writing notes and putting in orders/discharging patients, going to the operating room by 7:30 am, doing pre-op paperwork, operating most of the day, fielding consults in between cases, doing post-op paperwork and orders, seeing consults once I'm out of the operating room, doing post-op checks, going home and reading about the next day's cases, and then taking call covering all the major hospitals in the city at least once a week. I might get to see each of my inpatients 5-10 minutes per day. Do I like this? Absolutely not, but there's no other option, especially now that we have work hour restrictions.
b) Nurse practitioners come out of school with more clinical experience than medical students
8/10 pinocchios. When I was a medical student, I worked a lot, and I saw a lot. If you count every hour spent on the wards or in clinic as a clinical hours, we have thousands of hours of clinical experience by the end of medical school. Let's do the math. On average, as a third year medical student I probably was in the hospital working around 40 hours per week (this is very conservative, as lots more time was spent in additional lectures, etc.). With 4 weeks off to take the STEP, 1 week of boards, and 3 weeks of vacation, I probably worked 44 weeks my third year. I would count that as 1760 hours of clinical experience my third year of medical school. Fourth year was undoubtedly lighter compared to third year, but in the final two years of medical school I garnered at least 2500 hours of clinical experience. And intern year was still a big shock, not because I wasn't prepared, but just because of the magnitude of everything I was expected to know. Now this is partly student dependent, because we all know some students take much more out of their clinical experience than others, but I think that you get a tremendous amount out of your third and fourth years of medical school if you really wish to learn. I have nurse practitioner students rotate in one of our clinics on a pretty regular basis, and none of them have any interest in what we're doing; they come to half a day of clinic, mostly sit around on their cell phones, and count those hours towards their clinical experience.
c) Nurse practitioners order more tests than MD's
True from my experience. Now there are certainly lazy MD's who are also guilty of this, but from what I see, the primary care NP's where I work basically act as triage. You have difficulty urinating? Referral to urology. You're dizzy? Referral to ENT. Your nose is congested? Referral to ENT. Your back hurts? Referral to neurosurgery. Your knee hurts? Referral to ortho. You go back and look in the notes, and these complaints are rarely worked up, and they are hardly ever given any form of treatment. The practitioner just hears the complaint and immediately puts in the consult to the specialist. This undermines the entire point of increasing the number of primary care practitioners. Yes, patients can get seen by the NP quickly, and they can spend lots of time telling them about all their problems, but they don't actually get treated correctly until they are sent to a specialist. As a result, our specialty clinics are overflowing, and we have to run through patients as quickly as possible just to keep our heads above water. Most days we're seeing 45-50 patients, and if you want to get into clinic for a routine complaint, you're going to wait 3 months. This is terrible patient care, but it's the norm right now.
d) There is a place for nurse practitioners
Absolutely. I actually think that nurse practitioners are of more use in the specialties than primary care. If I could personally train a nurse practitioner to see and correctly treat the run of the mill conditions that come into my clinic, I could actually focus on the sicker patients who need more time, I could book more patients to go to surgery more quickly, and I could spend more time in the operating room. We have an amazing nurse practitioner who functions in this capacity, and she makes all of our lives better. She is nice to the residents and works well with us, she doesn't pretend to be the MD, and she always performs under the guidance of our attending. If all nurse practitioners could function like she does, I would be their biggest advocate, but unfortunately this just isn't the case.
How do we fix this?
I don't think there is any way to reverse this by legislative means; the NP's are already too far entrenched. I think the way we change this is by debunking many of their claims and changing the public persona about physicians. How do we do this? I think a documentary on the medical education system would easily change the public's opinions. Get a filmmaker to lay out the differences between MD and NP education in a film. Pull the ACT/SAT scores, college GPA's of the average entering medical student and directly compare this to that of the entering NP student. Actually show the enormous competitiveness and anxiety of being a medical student. Follow the lives of medical students, first through fourth years. Show how expensive it is. Show the immense amount of information that we are expected to master, the number of tests we must take, the USMLE's. Show the anxiety of the match. Show the indentured servitude that is residency. Directly compare each of these aspects to the NP training by focusing on actual students and their lives, the material, the rigor of the education. I think if you objectively, accurately portrayed this in a film so that the average person can truly see what the differences are, you would have a drastic change in the public's opinion of physicians.
And I'm off my soap box
